Healthcare Provider Details

I. General information

NPI: 1912811910
Provider Name (Legal Business Name): STAR DENTAL CANON CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 MACON AVE
CANON CITY CO
81212-3225
US

IV. Provider business mailing address

410 MACON AVE
CANON CITY CO
81212-3225
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-0128
  • Fax:
Mailing address:
  • Phone: 719-276-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: GARY MOORE
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 719-640-6407